Form Att-113 - Permit To Receive Tax Exempt Wine
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ATT-113 (Rev 1/13)
OFFICE USE ONLY
Georgia Department of Revenue
PERMIT #_____________
Alcohol and Tobacco Division
Telephone: (404) 417-4900
E-mail:
ATDIV@dor.ga.gov
Date _______________ 20_____
PERMIT TO RECEIVE TAX EXEMPT WINE
Submit online at
https://gtc.dor.ga.gov
In accordance with the Georgia Laws and Regulations relating to tax exempt wine, application is hereby made for approval
for shipment in the State of Georgia the below described wines for the use in sacramental services.
ORIGIN OF SHIPMENT: NAME OF LICENSE WINE WHOLESALER
FAX NO.
LICENSE NO.
STREET
CITY
STATE
ZIP CODE
DESTINATION OF SHIPMENT: NAME OF RECOGNIZED CHURCH OR SYNAGOGUE
FAX NO.
TELEPHONE NO.
STREET
CITY
STATE
ZIP CODE
14% OR LESS
OVER 14%
ALCOHOL BY
ALCOHOL BY
NUMBER OF
SIZE OF BOTTLE
LITERS PER CASE
VOLUME
VOLUME
BOTTLES PER CASE
CASES
LITERS
CASES
LITERS
TOTAL WINE TO BE SHIPPED …………………………………………….
GRAND TOTAL CASES PER THIS PERMIT __________ CASES.
___________________________________________
PRINT APPLICANT'S NAME AND TITLE
_______________________________
APPLICANT'S SIGNATURE
APPROVAL
Permit for the above described wine shipment is hereby granted and this constitutes authority to ship and transport in the State
of Georgia the above wine. This permit may not be changed, and if shipment is cancelled return this permit to Georgia
Department of Revenue, Alcohol and Tobacco Tax Division, 1800 Century Boulevard Suite 4235, Atlanta, Georgia 30345.
Date approved __________________________
By: _______________________________
Director or Designee
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